For Professionals

Thank you for being interested in helping families in Central Texas. The following links provide information about Perinatal Mood or Anxiety Disorders (PMADs) for health care professionals. Please feel free to contact us at info@pphatx.org for additional information and support.

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The Diagnostic and Statistical Manual for Mental Disorders, fourth edition (DSM-IV) does not differentiate postpartum–onset major depressive disorder (mixed or manic episode) from the symptoms in non-postpartum mood episodes. In order to diagnose PMADs with the DSM-IV, a postpartum onset specifier is required and states that the onset of the episode must be within four weeks post delivery. It is unclear from reviewing the DSM-IV or reference studies how this time period was determined. However, researchers and clinicians in the field of women’s health have begun to emphasize that postpartum depression (PPD) includes other symptoms such as increased anxiety, hyperarousal, and mood lability, symptoms that are not covered in the major depressive disorder diagnosis (Beck & Indman, 2005, Many Faces of PPD article).

When asked, women who are experiencing PPD describe many symptoms and feelings including loneliness, shame, feeling like they are on an emotional roller coaster, obsessive thinking, unrealness, fear of going crazy, loss of self, and fear of harming self or the baby; certainly not symptoms typically measured or used for standard depression diagnosis. Further, researchers report that the time period for the onset of postpartum depression varies from two weeks to 18 months. One year is the most commonly used time frame, with the onset predominantly within the first six months.

The DSM-IV includes the following one-page description of postpartum mood episodes: “The specifier “With Postpartum Onset” can be applied to the current Major Depressive, Manic, or Mixed Episode of Major Depressive Disorder, Bipolar I or II Disorder, or Brief Psychotic Disorder if the onset is within 4 weeks of childbirth. The symptoms of the postpartum-onset Major Depressive, Manic, or Mixed Episode do not differ from the symptoms in nonpostpartum episodes. Symptoms that are common in postpartum-onset episodes include fluctuations in mood, mood lability, and preoccupation with infant well being, the intensity of which may range from overconcern to frank delusions. The presence of severe ruminations or delusional thoughts about the infant is associated with a significantly increased risk of harm to the infant.

“Postpartum-onset mood episodes can present either with or without psychotic features. Infanticide is most often associated with postpartum psychotic episodes that are characterized by command hallucinations to kill the infant or delusions that the infant is possessed, but can also occur in severe postpartum mood episodes without such specific delusions or hallucinations. Postpartum mood episodes with psychotic features appear to occur anywhere from 1 in 500 to 1 in 1,000 deliveries and may be more common in primiparous women. The risk of postpartum episodes with psychotic features is particularly increased for women with prior postpartum mood episodes but is also elevated for those with a prior history of a Mood Disorder (especially Bipolar I Disorder). Once a woman has had a postpartum episode with psychotic features, the risk of recurrence is between 30 and 50%.There is also some evidence of increased risk of postpartum psychotic mood episodes among women without a history of mood disorders, but with a family history of bipolar disorder. Postpartum episodes must be differentiated from delirium occurring in the postpartum period, which is distinguished by a decreased level of awareness or attention.

“Women with postpartum Major Depressive Episodes often have severe anxiety and even panic attacks. Maternal attitudes toward the infant are highly variable but can include disinterest, fearfulness of being alone with the infant, or overintrusiveness that inhibits adequate infant rest. It is important to distinguish postpartum mood episodes from the “baby blues”, which affect up to 70% of women during the 10 days postpartum, are transient, and do not impair functioning. Prospective studies have demonstrated that mood and anxiety symptoms during pregnancy, “as well as the baby blues” increase the risk for a postpartum major depressive episode. A past personal history of nonpostpartum mood disorder and a family history of mood disorders also increases the risk of development of a postpartum mood disorder. The risk factors, recurrence rates, and symptoms of postpartum-onset mood episodes are similar to those of nonpostpartum mood episodes. However, the postpartum period is unique with respect to the degree of neuorendocrine alterations and psychosocial adjustments, the potential impact of breast-feeding on treatment planning, and the long-term implications of a history of postpartum mood disorder on subsequent family planning.”

Postpartum Depression

Criteria for Postpartum Onset Specifier:
Onset of major depressive episode must be within four weeks after delivery

Criteria for Major Depressive Episode:

A. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure. (Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.)

Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful)

Markedly diminished interest in pleasure in all, or almost all of the day, nearly every day (as indicated by either subjective account or observation made by others)

Significant weight loss when not dieting or weight gain (e.g., change of more than 5% body weight in a month), or decrease or increase in appetite nearly every day

Insomnia or hypersomnia nearly every day

Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

Fatigue or loss of energy nearly every day

Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

Diminished ability to think or concentrate, or indecisiveness, nearly every day (either subjective account or as observed by others)

Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B. The symptoms do not meet the criteria for mixed episode (p. 365 DSM-IV)

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general condition (e.g., hypothyroidism)

E. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

A Perinatal Mood or Anxiety Disorder (PMAD) is a familial disease. It affects the woman, her partner, and her children. With early intervention and treatment, it can resolve within one year, but without treatment it can become a chronic condition. Though screening is easy, effective, and inexpensive, only about 25% of OB/GYN patients had their psychiatric diagnoses recognized and only 20% of these diagnoses were treated.

Untreated mood disorders during pregnancy are associated with premature birth/low birth weight, increased miscarriage, and fetal hypoxia. Mothers show an increased use of addictive substance, are exposed to increased partner violence, are twice as likely to delay prenatal care and attend less than 50% of appointments.

Untreated postnatal mood disorders have a significant effect on their children, including:

PMADs are highly preventable and treatable. All of the above problems can be significantly reduced just by screening women and referring them to an appropriate provider (insert link). The Pregnancy and Postpartum Health Alliance of Texas recommends that any provider who has contact with perinatal women should routinely screen for PMADs, including:

Perinatal Mood or Anxiety Disorders (PMADs) have been called the most common complication associated with childbirth. Approximately 400,000 mothers in the United States experience postpartum depression each year. However, only a small proportion of these women are identified as depressed by health care professionals, and a large number of women fall through the cracks of the system.

Who routinely has the opportunity to discuss maternal psychological and physical transitions with new mothers? Ideally situated, obstetricians, midwives and pediatricians with their unique relationships with pregnant and parenting women, can provide a way to prevent and carefully identify PMADs. Research demonstrates that PMAD prognoses are best when identified and addressed immediately, thus stressing the need for screening in this population.

Before delivery, it may be possible to identify those women at highest risk for PMADs. These women would be candidates for more intensive monitoring, as well as certain interventions that may reduce the risk of postpartum illness in this high-risk group. Based on a meta-analysis of studies assessing risk factors for postpartum depression, Cheryl Beck created a list of 13 variables that may be used to identify women at risk for postpartum depression either during pregnancy or soon after delivery.

Ten items were validated as reliable predictors of postpartum depression:

Prenatal depression: depression during pregnancy may be the strongest predictor for later suffering from postpartum depression.

Prenatal anxiety

History of previous depression: although not as strong a predictor as a depressive episode during the pregnancy, it appears that women with histories of depression previous to conception are also at a higher risk of postpartum depression than those without.

Recent stressful life events

Inadequate social supports

Poor marital relationship: one of the most consistent findings is that among women who report marital dissatisfaction and/or inadequate social supports, postpartum depressive illness is more common.

Low self-esteem

Childcare stress

Difficult infant temperament

In addition, three factors are less definitively predictive, but still arise consistently as factors that increase a woman’s risk of a PMD, especially in combination with one or more of the factors listed above:

Single marital status

Unplanned or unwanted pregnancy

Lower socioeconomic status

The tools listed below have been demonstrated by research to be fast and effective in screening for PMDs:

There is a strong need for healthcare professionals to be trained to recognize and treat the symptoms of both antepartum and perinatal mood disorders. A variety of treatment options are available for women in the ante and postpartum period, such as psychotherapy, medication, or complementary and alternative therapies.

Perinatal Mood Disorder Treatments

Treatment of mood disorders during pregnancy is complex. A clinician must balance the aims of minimizing fetal exposure and limiting risk of maternal psychiatric illness, while also reducing the possibility of relapse.

The following steps are suggested for treatment planning in the pregnant patient (Stone, et. al, 2008).

STEP ONE – Weigh the Risks

While each woman should be considered on an individualized basis, it can be helpful to think about the severity of the disease on a spectrum. At one end of the spectrum are women who have experienced mild to moderate psychiatric illness recently but are not currently symptomatic. Generally, these women can be advised to go through pregnancy without medication. However, these women also need to know that their risk of a mood disorder during pregnancy is higher than that of women with no past psychiatric history. This category of women would likely benefit from psychotherapy to monitor and treat signs and symptoms should they arise.

On the opposite end of the spectrum are women who have severe recurrent illness, have been hospitalized, or have had severe exacerbations when going off medications in the past. Overall, this category of patient would be advised to continue their medication, as their risk of relapse is very high. Most women fall in the “grey zone” somewhere between the two extremes. These patients are the most challenging group for consultation because there is no easy answer for their treatment plan. The decision to stay on, discontinue, or change their medication during pregnancy must be made on a case-by-case basis, factoring in their personal values, beliefs, and individual ability to tolerate risks.

STEP TWO – Explore Non-medical Approaches

Psychotherapy offers a dual opportunity for treatment as well as regular monitoring of psychiatric symptoms. Many different types of therapy have been found to be successful in treating mood disorders in pregnancy. However, short-term, symptom-focused therapies may be more appropriate than psychoanalytically based approaches. Spinelli et. al (1997) found that interpersonal therapy is not only successful in resolving the symptoms of depression during pregnancy, but that it also protects against postpartum depression, making it as effective as medication for some women.

STEP THREE – Best Pharmacological Choices

When evaluating medication as a treatment option for the pregnant and postpartum woman it is important to consider the shortcomings of the available research literature. Specifically, pregnant and lactating women are typically not included in the majority of randomized, controlled clinical drug trials. Also, there are methodological flaws in the studies that gather data retrospectively, from large databases of national birth, drug company, and insurance company registries. Currently, no psychiatric drug has yet been approved by the FDA as being safe for use during pregnancy or lactation. This is despite the almost 30 years of research suggesting that many psychiatric medications are relatively safe.

Transfer of Medications to the Infant in Pregnant and Breastfeeding Women

Medications mothers take are transferred to their infants differently depending on whether taken while pregnant or breastfeeding. The following is a summary of a much-larger literature on selective serotonin reuptake inhibitors (SSRIs) use in pregnancy and in the postpartum period.

In Utero Exposure

During pregnancy, medications transfer to babies via the placenta and amniotic fluid. The amount transferred via the placenta is significant and can equal the mother’s dose. But medications differ in terms of how much they transfer, and using a medication that transfers in smaller amounts is one strategy for selecting a medication to use during pregnancy. For example, in a study of 38 pregnant women who were taking SSRIs, antidepressant and metabolite concentrations were found in 87% of umbilical cord samples. The mean serum ratios ranged from 0.29 to 0.89. The lowest ratios were for sertraline (Zoloft) and paroxetine (Paxil), and the highest for citalopram (Celexa) and fluoxetine (Prozac) (Hendrick, 2003). For handouts on psychotropic medications during pregnancy, visit www.otispregnancy.org.

With regards to SSRIs causing birth defects if administered during pregnancy, the Sloane Epidemiology Center Birth Defects Study recently confirmed that the overall risk of having a child affected by SSRI use was only 0.2% (Louik et al., 2007). They did note increased risk of three birth defects with SSRI use in the first trimester: omphalocele and septal defects with sertraline, and the heart defect right ventricular outflow tract obstruction with paroxetine. But only 2% to 5% of infants with these defects were exposed to SSRIs.

In neonates, third-trimester exposure can lead to “discontinuation” syndrome due to SSRI withdrawal. Discontinuation syndrome includes acrocynaosis, tachypnea, temperature instability, irritability, and elevated drug levels (Oberlander et al., 2004). Fortunately, these symptoms are generally mild and self-limiting, and can be managed with supportive care. Severe symptoms are rare, and no reported neonatal deaths have occurred that are attributable to in utero SSRI exposure. Discontinuation syndrome can be distressing to both mothers and babies, but the symptoms are self-limiting, last for 24 to 48 hours, and do not require further treatment.

Exposure via Breast Milk

Infants can also be exposed to maternal medications via breast milk, but the amount of exposure is substantially less than in utero exposure. Some medications are better than others in terms of amount of exposure the infant receives. A recent meta-analysis of 67 studies of antidepressant levels in breastfeeding infants pooled data from 337 research cases, including 238 infants (Weissman et al., 2004). The researchers had access to data on 15 different antidepressants and their major metabolites. They found that antidepressants were detectable in the breast milk for all the antidepressants they studied. Fluoxetine produced the highest proportion of elevated infant levels and the highest mean infant level. Citalopram was also relatively high. Only one infant across studies had an elevated paroxetine level, and that infant had also been exposed prenatally. All other infant paroxetine levels were zero, and this included three infants with prenatal exposure. Maternal dose was highly correlated with infant plasma level for citalopram. The correlation was weak for sertraline. And maternal dose did not predict infant level for fluoxetine, nortriptyline, or paroxetine. Compared with other antidepressants, fluoxetine was more likely to accumulate in breastfeeding infants.

With regard to long-term effects, the authors noted that low or undetectable infant plasma concentrations alone cannot reassure us that the antidepressant will have no effect on the rapidly developing brain, and whether chronic, low-dose exposure poses a risk. However, they noted that the studies with asymptomatic infants are reassuring. Moreover, they noted that although antenatal exposure differs from exposure via breastfeeding, the antenatal data suggests little or no long-term effects on developmental outcomes. They noted that we must factor in whether there was prenatal exposure as that provides a “loading dose” that far exceeds any exposure from breast milk and can thus distort findings regarding exposure via breast milk.

In summary, they noted that breastfeeding infants’ exposure to paroxetine, sertraline and nortriptyline are unlikely to have detectable or elevated plasma drug levels. In contrast, infants exposed to fluoxetine had higher medication levels, especially if they had also been exposed prenatally. Citalopram may lead to elevated levels in some infants, but more data are needed. Although these appear safe for the majority of babies, some adverse effects have been identified through case studies. Therefore, breastfeeding mothers should be advised to watch for any possible signs of adverse reactions including irritability, poor feeding, or uneasy sleep. Premature babies or babies with impaired metabolite efficiency should especially be monitored for adverse effects.

Psychotherapy Efficacy Studies:

Interpersonal Therapy (IPT)

O’Hara, 1993

Clark, R., Tluczek, A., and Wenzel, A (2003).

O’Hara and Stuart (2000)

Elkin, et al., 1989

Nylen, O’Hara, et al. (2010).

Cognitive-Behavioral Therapy (CBT)

Appleby, Warner, 1997

Urizar, 2011

Couples Therapy

Misri, I., Kostaras, X., 2000

Barnes, 2006

Goodman, 2003

Group Psychotherapy

Meager and Milgrom, 1996

Goodman, 2011

Milgrom, 2005

Complementary Therapies:

Phototherapy

Also known as light therapy, has been used to treat antepartum and postpartum depression. Oreb et al., 2002 demonstrated positive impacts on depressive symptoms when patients sat in front of a 10,000 lux light box each morning for 20-60 minutes.

This PPD Resources printout contains local resources and day-to-day tips and tricks that might help your clients. For more detailed information, please search through the “For Mothers” section of the website.

Lane, B., Roufeil, L.M. Williams, S., et al. (2002). It’s just different in the country: Postnatal depression and group therapy in a rural setting. Social Work Health and Mental Health: Practices, Research and Programs, 333-348.

PPHA encourages all professionals who come in contact with perinatal women and adoptive parents to seek maternal mental health training. If you are interested in obtaining a PPHA training for you or your staff, please contact us at info@pphatx.org. Please note that all providers wishing to be listed on our provider list will be required to complete maternal mental health training within the first year.

Other sources for maternal mental health training:

MedEd PPD:www.mededppd.org. Click on Multimedia/Education and then Presentations for 9 core learning modules.

2020Mom: www.2020mom.org. Presents a free basic overview of maternal mental health, or a more in-depth 8 session webinar for $480.

PPHA is happy to provide training. These trainings are free and geared toward professionals and professional staff. To request a training session, please contact us at info@pphatx.org.

About Us

This website contains information about Perinatal Mood Disorders (PMDs) for women, their families, and professionals. We recognize the need for perinatal support in Central Texas is great. Our goal is to connect families with services and adapt as needs change. Please visit the website often for updates. Click here to read more.